Reducing Pre-registration Attrition and Improving

Retention – RePAIR

Purpose of the RePAIR study The RePAIR project was established to deliver an aspect of the Department

of Health’s HEE 2015 refreshed Mandate.

6.19 Unnecessary attrition from training programmes can result in significant cost and impact on the health and wellbeing of students. HEE’s objective is to reduce avoidable attrition from training programmes by 50% by 2017.

“ RePAIR has enabled us to rekindle the discussion.”

Theoretical Framework

Higher education commitment

Healthcare provider/ clinical

education commitment

Student commitment

Understanding indicators of attrition HEE’s RePAIR definition Pure attrition is the number of students who did not complete on time within the standard pathway for that programme, i.e. within three years for the majority of programmes.

Pure attrition = Non-completers/starters x 100, • Number of non-completers, i.e. the total number of students who withdrew or interrupted, for any reason, from

the cohort to which they were recruited before the programme end date, including those who transferred out to other cohorts and programmes

• Number of starters, i.e. the total number of students recruited to a given programme

Unique dataset 2013/14 and 2014/15 33.4 % did not complete on time

Most students who experience an interruption complete their studies within a further 24 months of the standard pathway Analysis of HESA high level data trends using observed expected attrition metric revealed the percentage change improvements overall in years two and three were in the region of 50%

Developing our understanding

Group Number Students 155

Newly qualified practitioners

25

Academics 67

Clinical educators

63

Policy advisors 7

PSRB representatives

7

Focus groups

Region Number North 4

Midlands and East

3

London & South East

5

South 4

Case study sites

Key survey findings 1 Mostly positive findings

• 97 per cent intend to pursue a career in their chosen degree field within the next three years

• 87 per cent would recommend their course to a friend and/or family • 93 per cent agreed their university-based learning had been a positive

experience • 96 per cent agreed that they had made the right decision in enrolling on

the course

Key findings 2

Challenging findings which if unaddressed could potentially affect the supply of newly qualified practitioners

• 74% agreed that they fear getting into more and more debt

• 85% agreed that paying for travel for placements is a struggle

• 63% of those in receipt of a bursary would not have applied for the course if they had been required to pay course fees

– 70% from London and South East vs 50% from the North

– 44% of the 17-20 year olds; 76% of 23-30 year olds; 78% 41 and above

Key findings 3 Student expectations • It is important that the sector does not overstate the learning experience and

ensures all students are clear about the system’s expectations, including supernumerary status

“ The most important criteria when choosing my current university were NHS

bursary, reputation, placement providers, distance from my current residence. ” 2nd year adult nursing student Midlands & East

• The level of support, provided by HEI staff, for students while in clinical placement ranges from consistent to non-existent

Support from the HEIs for students while in clinical department

Key findings 4

Generation gap

“ How good are the universities at making sure the service knows what the new group of 21 year olds

want in comparison to a group of 35 year olds, who will behave very differently? ” Course tutor

Course planning and organisation – students’ requests

Allocation of clinical placements one year in advance, the approach to placement allocation needs to improve Less disorganisation Greater awareness of the academic workload and clinical demands especially Year 2 Level of support is really important

Key findings 5 Year 2 wobble • Average of 41% of the students have considered leaving the course

– 18% Year 1 respondents – 48% Year 2 respondents – 56% Year 3 respondents

The mentor/supervisor-student relationship

• Students reported a very mixed experience and explained that the support offered by mentors is key to the success of their clinical learning outcomes

The pressure in the clinical environment

Students explained that they are very aware of the clinical service pressure and the impact it has on their clinical learning opportunities.

The pressure in the clinical environment Students explained that they are very aware of the clinical service pressure and the impact it has on their clinical learning opportunities.

“ Placements are a complete lottery, some are fantastic

learning environments, while others are struggling to provide sufficient care let alone accommodate students ”

3rd year mental health nursing student – London & South East

‘First placement was excellent and I couldn't fault it, but the second was dis-heartening, no time for students, treated as a healthcare assistant, no support at all, some nurses had no respect for me as a student and refused to let me watch or do anything! But three nurses did, so I made sure I followed them whenever possible. When qualified I will not be applying for a job at that hospital.’

2nd year adult nursing student – Midlands & East

Key findings 6

Key findings 7 Expectations of students’ role in the clinical

‘It is very dependent on where you are placed but, there is sometimes a culture out there that students are there to do all the little jobs the staff don't want to do: “This patient needs escorting where's the student? they can do it”. This leads to the view that students do all the jobs that no one else can be bothered to do or they're just happy to get us out of the way for a while, we sometimes feel like a burden.’

2nd year adult nursing student – Midlands and East

Key findings 8

‘Preceptorship is the golden nugget in your flaky bridge.’

Education and training development lead

Key findings 9 Preceptorship

‘The word on social media is that this is one of the best preceptorship programmes because of the support structure that the preceptees have during the first 12 months’.

Recommendation 1 Standardisation of indicators of attrition

National bodies should work together to review the current range of definitions of attrition, and model(s) for measuring this metric, to ensure that the output data is meaningful to all parts of the sector, in particular the HCPs.

Recommendation 2 Cost effectiveness of interventions

HEIs and HCPs should work in partnership to acquire a better understanding of the cost effectiveness of interventions that are designed to improve retention.

Recommendation 3 Funding support

HEE should seek ways to make hardship funds available to encourage more prospective students, particularly mature students, to embark on a career in nursing, midwifery or therapeutic radiography.

Recommendations from RePAIR Recommendation 4 Wrong career choice

HEIs should ensure clinical staff are actively involved in recruitment and the prospective students do understand the career they have chosen to enter and the demands of the course.

Recommendation 5 Buddy schemes

HEIs should review, in partnership with their students, the institution’s approach to buddy schemes for healthcare students.

Recommendation 6 ‘Year 2’ students

HEIs and HCPs should work together to develop specific programmes of support for second year students.

Recommendation 7 Placement allocation and associated costs HEIs should work more closely with their HCP partners and map out detailed placement allocations for all the students, throughout the duration of their course. They should also review processes relating to placement costs and ensure students are reimbursed in an efficient and timely way.

Recommendation 8 National model for support in practice HEE should work with HCPs and HEIs to ensure that its’ national strategy, to support students in clinical practice and their supervisor/mentors, is implemented.

Recommendation 9 Clarity of students’ role in practice HCPs and HEIs should work together to resolve the dissonance that exists concerning some students’ understanding of their role in the service and the interpretation of students’ supernumerary status, particularly for third year students.

Recommendations from RePAIR Recommendation 10 Standardised clinical assessment HEIs should work together to agree a national standardised approach to assessing students’ clinical competence, including a simple process of recording students’ prior clinical experience.

Recommendation 11 Levels of student confidence HEIs should develop a clearer understanding of the factors that affect student confidence levels, particularly at the point of progressing from student to newly qualified practitioner.

Recommendation 12 Preceptorship as aid to retention HCPs should review their preceptorship programmes to improve recruitment and retention of their newly qualified staff and ensure preceptors are appropriately trained.

Recommendation 13 Recruitment of newly qualified practitioners

Neighbouring HCPs should work together, and with their local education providers, to agree a shared model of recruiting newly qualified practitioners.

Recommendation 14 Impact of culture of care

HCPs should gather data about the culture of care I in the clinical environments, in which the students are training, to understand the impact of that culture on the students and their early career decisions.

Recommendation 15 Application of RePAIR to new models of pre-registration education and training

HEE should seek to understand the relevance of the findings from RePAIR to the new models of pre-registration education and training that are being implemented in health and social care.

Recommendations from RePAIR

How organisations can support RePAIR?

• Get RePAIR on the agenda • Organisational commitment to student learning • Consider your approach to mentorship/student supervision • Communicate expectations clearly to students • Standardise Practice Assessment Documentation • Value year two students • Remember Culture of Care impacts on students and the

choices they make as they embark on their professional career

• Support the collection of data in particular about RePAIR Steps 3 and 4 of the student journey.

Outputs from RePAIR • RePAIR toolkit - interactive PDF • Economic cost calculator • Examples of good practice • Report • Study summary https://www.hee.nhs.uk/our-work/reducing-pre-registration-attrition-improving-retention

Final message from RePAIR

Stakeholders (students, higher education institutions and healthcare providers) must all do better to increase their commitment to each other in order to improve retention and own the individual contribution they can make to reduce attrition.

RePAIR programmes next steps RePAIR recommendations

https://www.hee.nhs.uk/our-work/reducing-pre-registration-attrition-improving-retention

1.Standardisation of indicators of attrition

2. Costs of interventions to improve retention

3. Financial pressures

4. Wrong career choice

5. Buddy Schemes

6. ‘Year 2’ students *

7. Placement allocation and associated costs

8. National model of support for students in the clinical department

9. Students’ role in the clinical department

10. Standardised approach to clinical assessment

11. Levels of student confidence *

12. Preceptorship model as an aid to recruitment and retention¨

13. Recruitment of newly qualified practitioners

14. Impact of culture of care and early career choices *

15. Application of RePAIR to new models of pre-registration education and training

RePAIR Legacy projects (2018-2019)

1. Valuing Year 2 students *

2. Impact of the Culture of Care *

3. Transition shock and levels of self-doubt *

4. Early career choices

5. Late and end of career choices

6. Clinical Training capacity~

RePAIR Implementation Programme (RePAIR II)

Domains (2019-2021)

A. Building the practice learning capacity~

B. Learner clinical supervision and support

C. Preceptorship toolkit ¨

D. On-line platform to support student and staff placement communication

Key: *Projects developed from RePAIR recommendations ¨ Domain built on RePAIR recommendation 12 ~Domain to include RePAIR Legacy project 6

RePAIR Legacy projects

1. Valuing Year 2 students 2. Impact of the Culture of Care 3. Transition shock and levels of self-doubt 4. Early career choices 5. Late and end of career choices 6. Clinical Training Capacity

RePAIR celebrations October 12th 2018

RePAIR Implementation Programme Domains (2019-2021)

A. Building the practice learning capacity

B. Learner clinical supervision and support

C. Preceptorship toolkit

D. On-line platform to support student and staff placement communication

A Partnership Programme

Council of Deans of Health, Healthcare Providers, HEE

Four regional delivery teams

16 part-time RePAIR Fellows